Went to an interview with MW today who had done nearly 400m births, I asked if she had any fatalities, and she had one. I was the baby and she said he had aspirated badly on muconium (sp). I asked if there was any in the waters when they broke and she said the water didn't break until the last minute, and the baby came right away and it was out of her hands. (she was teary eyed at this point)

So my thinking is there was nothing she could have really done in this situation(besides of course trying to suction it out)...would you say that was correct or that this should be a red flag for me?

Thanks!

Young born-again mama and loving wife to DH and SAHP to two crazy girls we and believe !

I am not one of the educated ladies but ran across your post. In light of the lack of other responses -- I do believe that meconium aspiration has been linked to fetal distress/hypoxic events (deprivation of oxygen before or during birth). Perhaps someone more educated could correct me if I am wrong?

So -- it may be that she did not appropriately transfer a woman whose baby was showing signs of fetal distress/oxygen deprivation and that the fetal distress resulted in the mec. aspiration which resulted in death. Or she may not be at fault at all.

Have you asked her what she feels she could have improved upon during that labor? What would she do differently based on that experience? Has she sought out any further education or skills that might be applicable in light of that experience? Or is she all "some babies are meant to die" about it?

Hmm the only thing that came to me was about the water breaking I did not think to ask about the fetal distress. When I asked what happened she got teary eyed and I actually said "1 out of 400" is low anyway and she said "No it is not" you could tell she was effected by the death.

I would not think it was lack of training or anything b/c she actually teaches courses and seminars on midwifery and all sort of births.

I guess I should ask her to go into more detail.

Thanks for replying!

Young born-again mama and loving wife to DH and SAHP to two crazy girls we and believe !

She is correct -- 1 out of 400 is not low. It is much higher than the average rate of perinatal mortality, especially given that midwives should be dealing with a low risk population.

Honestly, I think this is one place to turn your (natural) sympathy for her distress off and consider deeply both the best interests of your baby and yourself. Perhaps this was an unavoidable accident, perhaps not. Only you can decide if you are comfortable with proceeding with her.

She is correct -- 1 out of 400 is not low. It is much higher than the average rate of perinatal mortality, especially given that midwives should be dealing with a low risk population.

Yes but it doesn't mean she truly has a higher than average rate of mortality. She could go on to attend 1000 births with no complications. Your "one" is randomly "assigned". It could be the first birth you attend which would give you a mortality rate of 100% but that wouldn't be a true reflection of your actual mortality rates.

OP, mec aspiration is real problem and, once it's in the lungs, the only options are supportive treatments which require NICU. There may or may not have been any signs of distress evident before the waters broke. If it was thick mec then I would say that *usually* you would have some indication. Thin mec, less likely to be signs beforehand but can still result in mec aspiration syndrome.

I do not think it would be rude to email her at all. She may find it easier to discuss via email than face to face if she is still feeling raw about it. I would ask if there were any indications prior to birth, what type of monitoring she was doing (of both mother and babe), what action she took once she realised there was mec present in the waters (both before and after the baby was born) and if there is anything she would do differently next time.

You can have a bad outcome at any point. The important things are how you dealt with it and what you learned from it.

The MW probably missed the signs of distress, but it's not totally her fault, its the fault of the lack of technology available at home.The problem is there is no good way to check for fetal distress due to meconium at home. If the water doesn't break and show the mec, there is no way to know at home, besides knowing mom is post dates, which frequently (but not always) is accompanied by mec. A Doppler is good, and hears the heartbeat, but you can't hear the decels or other very subtle signs of distress with it. You need to be able to see a graph for that, as the ear cannot distinguish the slight difference in beats, or the lack of variability at shows severe distress (there are clips online so you can listen for yourself, if you don't believe me).

Not having a NICU and peds right there for resuscitation is another danger. If you don't catch the mec until the birth, and babe is already severely compromised, then requires transport, it may be too late. At a hospital, you might end up with an induction or emergency CS, but the distress would most likely be caught. I know all hospitals and CNM/Obs are perfect, but standard procedures typically pick up this type of problem. (if not, its considered malpractice!)

HB in general has certain risks, and the risk of less monitoring and no NICU is one of them. I interviewed a HB MW for my upcoming labor, and she was clear about the lack of monitoring, and how it makes a difference for things like mec, abruption and rupture. Only you can know for yourself if this is a risk that is worth it, or if it is outweighed by benefits. *I am not anti HB, and attempted a UC, and am attempting another this year. I just think its important to know the weak points of HB (or UC or the hospital) to make an informed choice. I also attended births with a MW in Mexico for a few years, but am not a professional (was going to be, but decided not too)

What I would want to know about the MW is whether the family was compensated for the loss (money won't bring baby back, but will help pay for a funereal and other related costs, like therapy), and how the mom was treated afterwards. I have 2 dear friends with HB losses, and their MWs turned on them, and were very mean. It was very sad to see a cherished MW act this way, no one expected it. Its always good to Google her, and also see if the state keeps records on their stats (most don't).

. A Doppler is good, and hears the heartbeat, but you can't hear the decels or other very subtle signs of distress with it. You need to be able to see a graph for that, as the ear cannot distinguish the slight difference in beats, or the lack of variability at shows severe distress (there are clips online so you can listen for yourself, if you don't believe me).

You absolutely can detect decels with a handheld doppler. *But* you need to listen continuously before, during and after a contraction and most people don't seem to do that routinely.

Variability is harder to detect but what you should be able to hear is a lack of reactivity which usually preceded a loss of variability.

I agree -- the monitoring level is one of the key differences between hospital and home birth.

In the hospital, the issue is that the fetal monitoring turns up a lot of false positives. Generally, I understand that non-intermittent hospital monitoring should "catch" all cases of fetal distress. However, it does turn up a fair number of babies that might appear to be distressed on the monitor but are actually not -- leading to an unnecessary intervention.

At home, monitoring is not as effective and will not catch all cases of fetal distress. So your baby may have fetal distress/hypoxic events and you may be unaware of it. However, because there are rarely the sort of false positives that may exist with hospital monitoring, your chances of an unnecessary intervention are reduced.

Also, katelove, given the stories I have read where midwives have mistaken the heartbeat of the mother for that of the baby (in scenarios where the baby clearly died much earlier in the labor than the midwives believed) --- hearing fetal distress with a doppler may be generally possible, but not everyone has the actual skill/ability to hear it.

Also, katelove, given the stories I have read where midwives have mistaken the heartbeat of the mother for that of the baby (in scenarios where the baby clearly died much earlier in the labor than the midwives believed) --- hearing fetal distress with a doppler may be generally possible, but not everyone has the actual skill/ability to hear it.

Well yes, of course it does depend on your midwife's level of skill. That holds true for most things. You should always check and document the mother;s heart rate at the same time as you check the baby's to avoid the scenario you mention.

actually studies show intermittent listening of the fetal heart rate is just as safe and effective as continuous monitoring without the side effect of false positives, however most hospitals use them because it makes it easier for them, they can come in and look at a strip and not have to actually do anything. Jane, have you actually studied anything about midwifery or safe childbirth practices? You seem to be very keen on posting about things without having the actual information.

Quote:

Originally Posted by Jane93

I agree -- the monitoring level is one of the key differences between hospital and home birth.

In the hospital, the issue is that the fetal monitoring turns up a lot of false positives. Generally, I understand that non-intermittent hospital monitoring should "catch" all cases of fetal distress. However, it does turn up a fair number of babies that might appear to be distressed on the monitor but are actually not -- leading to an unnecessary intervention.

At home, monitoring is not as effective and will not catch all cases of fetal distress. So your baby may have fetal distress/hypoxic events and you may be unaware of it. However, because there are rarely the sort of false positives that may exist with hospital monitoring, your chances of an unnecessary intervention are reduced.

Agreed with katelove: You absolutely CAN hear decels and somewhat variability with a doppler. Most midwives are trained well enough to hear it and if they are not should be aware of it and willing to learn.

Also agree with newsolarmomma: its the risk you take with a home birth.

newsolarmomma: what would you expect compensations to be? The midwives fee? or more than that? The hospital only 'compensates' if they are sued. And most people agree that we are suithappy here in the States.

Its so difficult to judge a midwife's bad out come without knowing the ins and outs of the situation involved : / I think the fact that you worked out a deal already and decided you liked her is a big deal, if you have a 'peace' about it that really is the important thing.

Well -- at least I'm not someone who claimed that a mortality rate of 1/400 wasn't something to at least give extra consideration to!

My understanding is that our two local hospitals (one being a top university hospital in ob) that the protocol used is intermittent monitoring until something concerning arises with labor (for example -- mec stained waters) at which point continuous monitoring is used.

I find it interesting that you claim that intermittent monitoring doesn't lead to an increased rate of false positives. What about the "dreaded cascade of interventions" of hospital birth based on fetal monitoring?

Also -- if we are going to discuss the nitty gritty on EFM, please note that the Cochrane review on fetal heart rate monitoring is very problematic. It was not large enough (only 37,000 births) to really demonstrate the effectiveness/ineffectivenss of fetal heart rate monitoring. Also, of the data included in the Cochrane meta-analysis "it is noteworthy that there are someconcernsregarding the 12 RCTs, whichsampled 37,000 women. Only 2 of thesetrials are of high qualityand only 3trials reported data in low-risk women."

The Chen paper instead looked at roughly 1,700,000 births and with its principal finding being that "EFM use during labor was associatedwith a significantly lower early neonataland infant mortality" with the benefits of EFM increasing substantially for premature infants. You can check out the paper in the June 2011 ACOG journal, its entitled "Electronic fetal heart rate monitoring and its relationship to neonatal and infant mortality in the United States" by Chen, et. al.

Are you aware that the Chen paper compares EFM to no monitoring at all? In discussing EFM compared to intermittent auscultation, it's a useless paper to be citing. Cochrane's research remains the best that we have.

1/400 is high, but if you bothered to read the above posts it gives a good explanation as to why that isnt an accurate way to view it.

you must have rare hospitals then considering the usage rate is over 60% on average.Some places are as high as 90%.

The cascade of interventions is based on Continuous electronic fetal monitoring, not intermittent.

I really really wish you would do some research and actually learn about these things before you post

Quote:

Originally Posted by Jane93

Well -- at least I'm not someone who claimed that a mortality rate of 1/400 wasn't something to at least give extra consideration to!

My understanding is that our two local hospitals (one being a top university hospital in ob) that the protocol used is intermittent monitoring until something concerning arises with labor (for example -- mec stained waters) at which point continuous monitoring is used.

I find it interesting that you claim that intermittent monitoring doesn't lead to an increased rate of false positives. What about the "dreaded cascade of interventions" of hospital birth based on fetal monitoring?

What would you do if you detected an abnormality when monitoring the foetal heart?

I would expect an answer along the lines of "It depends what the abnormality was" but she should be able to give some details such as "check mum's vital signs, recheck the foetal heart at the next contraction, ask mum to change position, encourage mum to drink more fluids etc". She should have some sort of plan and she should be able to interpret a general question. You shouldn't have to ask specific questions like "what if you found foetal tachycardia?" "bradicardia?" "late decels?" Although, of course you can if you want to.

What type of emergency equipment do you carry?

I would expect suction and a bag-valve-mask device as a minimum. Oxygen would be good but not essential. IV fluids and syntocinon (Pitocin in the US, sorry, not sure where you are) for bleeding. Although I believe in some places they are not allowed to have these. In that case I would want to know how she would control excessive bleeding.

How often do you update your resuscitation certification?

Should be at least yearly. And, if she carries IV equipment should include a cannulation refresher.

What are your criteria for transferring to hospital?

What is your current transfer rate?

That's all I can think of off the top of my head. I'll come back if I think of any more and maybe someone else will have some ideas also.